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Equine Surgery: QOD > Orthopedics > Flashcards

Orthopedics Flashcards

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1
Q

Draw and name the types of ulnar fracture

A
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2
Q

Draw and name the types of Salter-Harris fracture

A
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3
Q

What are the options for pastern arthrodesis (medical and surgical)? Include names/descriptions of implants also

A

Injection of 75% ethyl alcohol

Casting

Ideally: PIP arthrodesis LCP - 3 hole narrow LCP with 2 transarticular cortex screws

Dorsal 3-hole narrow DCP or LCP combined with 2 transarticular cortex screws

2 places, T-plate, Y-plate also possible (requires 5.5mm transarticular screws)

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4
Q

Describe the tarsal drilling technique for tarsal arthrodesis

A

GA, lateral/dorsal recumbency

From dorsomedial aspect of tarsus

Sterile prep and drape

3cm skin incision on dorsal medial aspect of TMT and DIT joints

Drill entry midway between line extending form groove between proximal MTII and MTIII and most dorsal asset of distal tarsus (plantar to saphenous vein).

Needles used to identify joint spaces with rads/fluoroscopy

Tracts drilled in pairs (TMT and DIT). 4.5mm drill bit

20mm directed to lateral palpable extremity of MTIV

20mm angled 30 degree to first tract in plantar direction

35mm tract angled 30 degrees to first in dorsal direction

Incision closed subcutaneous (continuous 2-0 absorbable) and skin (interrupted 2-0 absorbable)

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5
Q

Which is the most common digit to be a supernumerary digit

A

Medial aspect of forelimb in 80% of cases

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6
Q

List the causes of exostosis of the splint bones

A

Trauma:

Subperiosteal hemorrhage

Elevation of periosteum

Instability between MCIII and MCII

MCII fractures

Inflammation of intercarpal ligament:

Can result from circles on a hard surface

Or conformation abnormalities (bench knees)

Carpal varus

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7
Q

Describe the post-op care after splint bone removal

A

Post-op:

Pressure bandage for 2 weeks

Stall rest 1 month

2 months handwalking/small paddock turnout

Radiography to assess stability of proximal fragment

Drain may be required for 2-3 days

NSAIDs

ABs depending on drainage and incision

Full limb cast may be required for recovery and post-op if whole MTIV removed

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8
Q

What is the endurance limit of metallic implants

A

Maximum stress below which a material can endure an infinite number of stress cycles

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9
Q

What is shot peening

A

Done before electropolishing

Implant subjected to high-velocity impaction by metallic or ceramic particles

Produces roughened surface with increased residual compressive stress for enhanced fatigue life

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10
Q

List all the medical and surgical options for management of strain-induced tendinitis

A

Non-surgical therapies:Physical therapies:

Cold therapy:

Compression and coaptation:

Corrective shoeing

Controlled exercise:

Extracorporeal shock wave therapy:

Therapeutic ultrasound, laser and magnetic fields:

Counter-irritation: (not effective)

Pharmacologic management:Systemic medication:

Corticosteroids:

NSAIDs:

DMSO

Intralesional medication:

PSGAGs:

HA:

Component of tendon matrix

Beta-aminopropionitrile fumarate

Methylprednisolone: (avoid)

New advances: Tissue engineering approaches:

IGF-1:

Recombinant equine growth hormone:

TGF-B:

PRP:

TGF-B

VEGF

ACELL VET:

Bone marrow:

MSCs:

Surgical therapies:

Tendon splitting:

Desmotomy of the accessory ligament of the superficial digital flexor tendon:

Tenoscopy:

Bursoscopy:

Annular ligament desmotomy:

Fasciotomy and neurectomy of the deep branch of the lateral plantar nerve for the treatment of proximal suspensory ligament desmopathy:

Desmotomy or desmectomy of the accessory ligament of the deep digital flexor tendon

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11
Q

List the methods of diagnosis of strain-induced tendinitis

A

Clinical history

Palpation

Ultrasonography

Molecular markers:

PICP

COMP

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12
Q

Why do intrathecal tendon lesions heal more slowly than other tendon lesions

A

No paratenon

Reduced extrinsic repair

Synovial fluid slows repair

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13
Q

Describe the phases of tendon healing

A

Inflammatory reaction:

Increased blood flow

Edema

Neutrophils, macrophages, monocytes

Proteolytic enzymes

Also further damages tendon

Reparative phase:

After a few days, lasts several months

Angiogenesis

Fibroblastic cellular infiltration (extrinsic repair)

Limited intrinsic repair

Scar:

Higher ratio of Collage III to collage I (50% cf 10% in normal tendon)

Higher hydration

Higher GAGs

Reparative phase:

Type III to type I collagen as scar matures

Thicker collagen fibrils and cross-links increase

Mature scar less stiff than tendon but as there is more tissue, scar tissue actually more stiff

Result: strong but functionally inferior tendon, predisposing to reinjury

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14
Q

What are the most common intrathecal tendon lesions in the forelimb and the hindlimb

A

Forelimb: Bursting of lateral border of DDFT

Hindlimb: Manica flexor of SDFT

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15
Q

What is the prognosis for horses with a peroneus tertius rupture

A

78% midbody/insertion returned to previous level of work

21.7% euthanized

Premature return to exercise assocaited with re-injury

Monitor with U/S

If avulsion fracture: guarded

Age, open/closed injury, U/S size, location, duration of rehab had no influence on return on exercise

Racing at time of injury reduced prognosis

If additional structures damaged, 8 times less likely to return to soundness

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16
Q

What is the prognosis for horses with a peroneus tertius rupture

A

78% midbody/insertion returned to previous level of work

21.7% euthanized

Premature return to exercise assocaited with re-injury

Monitor with U/S

If avulsion fracture: guarded

Age, open/closed injury, U/S size, location, duration of rehab had no influence on return on exercise

Racing at time of injury reduced prognosis

If additional structures damaged, 8 times less likely to return to soundness

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17
Q

Describe the procedure for semiteninosus tenectomy

A

GA, lateral recumbency

Landmarks:

Tibial insertion of muscle on caudomedial aspect of tibia just distal to medial femorotibial joint and caudal to saphenous vein overlying gastrocnemius muscle

8cm vertical incision made over palpable tendon and through subcutaneous and crural fascia until tendon exposed

Kelly/crile forceps passed under tendon to isolate from muscle and tendon transected

Resection of 3cm segment (prevents of delays recurrence)

Fascial layers closed with interrupted or continuous synthetic absorbable sutures

Skin closed with interrupted or continuous non-absorbable suture

Pull limb forward; if tendon of insertion of semitendinosus muscle onto calcaleal tuber taut:

3-4cm incision directly over tendon (caudal and distal to first incision)

Isolate and transect

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18
Q

How does fibrotic myopathy occur

A

Adhesions and fibrosis of semitendinosus (or semimembranosus, biceps femoris, gracilis) muscle

Secondary to IM injections, trauma (lacerations, slipping, kicks) or tearing insertion of semitendinosus while barrel racing, lameness

Can be caused temporarily by breach bar

Can occur as neonates

If involves both limbs, likely neuropathy is the cause

Ossifying myopathy: when bone forms in affected tissue

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19
Q

Describe the procedure of a lateral digital extensor penectomy and partial myectomy

A

Remove distal 2-10cm of LDE muscle and entire tendon

Standing or GA (can remove more muscle under GA)

Sites:

Junction of LDE tendon with log digital extensor tendon on lateral aspect of metatarsus

LDE 2cm proximal to lateral malleolus

Distal incision made directly over tendon just proximal to junction with long digital extensor tendon

Blunt dissection beneath tendon with curved kelly or Ochsner forceps

Proximal incision on lateral aspect of limb 6cm above lateral malleolus (skin, subQ and fascia directly over lateral digital muscle parallel with muscle fibers)

Blunt dissection to expose muscle belly and heavy curved instrument placed underneath it

Sever at distal incision and pull through by traction on proximal section with curved Ochsner forceps of Mayo scissors

Muscle severed at proximal aspect of incision, ensuring at least 2cm muscle removed

Close fascia proximally with simple interrupted or continuous USP 0 absorbably suture

Subcutaneous 2-0 absorbable simple continuous

Skin non-absorbable simple continuous

Distal incision with skin sutures only

Sterile dressing and whole limb bandage 10-14 days

Stall rest 2 weeks

1 week hand-walking

Normal exercise in 2-4 weeks

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20
Q

What are the treatments for cribbing (medical and surgical)

A

Non-surgical:

Pasture turnout

Remove objects that horse cribs on

Cribbing straps

Acupuncture

Aversion therapy

Surgical:

Forssell procedure

Modified Forssell procedure

Bilateral neurecomy of the ventral branch of the spinal accessory nerves

Surgery of choice is to combine modified Forssell procedure with bilateral neurectomy

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21
Q

Puncture of the sole of the foot by a nail can involve which structures

A

P3

Navicular bone

DIP jt

Navicular bursa

DDFT

DFTS

Sole

Digital cushion

Laminae

Heel bulbs

Palmar cartilages of P3

Collateral ligaments of DIP jt

Impar ligament

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22
Q

How should keratomas be managed

A

Remove keratoma up to origin:

Can resolve inflammatory process first or can remove immediately - depends on level of lameness

Altered horn and altered sensitive lamina must be removed

Surgery:

Tourniquet

Standing/ring block or GA

Remove as much horn as possible with horse standing until Dremel tool exchanged for scalpel and curettes

Aseptic prep

Altered lamina and entire keratoma removed in toto

Aseptic pressure bandage applied to plalangeal region

Bandage changes at 3-4 days intervals under aspectic conditions

Support to hoof wall

Medication plate can be applied as soon as granulation tissue

Fill hoof wall defect with artificial horn as soon as sensitive lamina healed

Shoe with large clips on either side of defect

Post-op:

Stall rest 4-6 weeks

Reshod

Light walking after 2-4 months if healing good

If re-infection, remove all affected tissues and start process again

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23
Q

List the methods of treating canker

A

Removal of abnormal tissue surgically using knife/blade

Cryotherapy

Surgery likely to be repeated

Clean with povidone-iodine with bandage changes every 2-3 days

Apply shoe with pad

Daily bandage changes with 20g iodoform iodine, 20g zinc oxide, 20g tannic acid, 40g metronidazole

OR Chloramphenicol + metronidazole

Systemic ABs if more than one hoof affected (doxycycline or oxytetracycline)

Biotin and zinc added to feed

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24
Q

List and draw the types of P3 fracture

A
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25
What are the surgical options for treating laminitis
DDF tenotomy (mid carpal or pastern approach) Hoof wall resection
26
List all the causes of ALD
Perinatal:Incomplete ossification:Mare: Placentitis Metabolic disease Parasite infection Colic Foal: Premature Twins Uneven loading of joints due to mild ALD Osteochondral fractures may occur in severely dysmature (esp dorsal aspect small tarsal bones) Laxity of periarticular structures: If ALDs of several regions and rotational deformities Due to laxity or soft tissue trauma Laxity lead to abnormal loading and can incide ALD if incomplete ossification Causes: Hormonal imbalance Intrauterine positioning Aberrant intrauterine ossification: Deformed long bone at birth Caused by mechanical factors leading to deformation of precursor cartilage Distal physeal region on MTIII involved; triangular epiphysis and varus deformity Developmental:Unbalanced nutrition: Excessive intake - too much grain from crib feeding Unbalanced trace minerals:Caused by: Zinc toxicity Copper deficiency Ca:P Excessive exercise and trauma: Microfractures/crushing of proliferative zone Type V Salter-Harris Epiphyseal fractures from kicks Physeal trauma: Salter-Harris type V or IV Local retardation on medial or lateral aspect Compensatory: Proximal phalanx due to prolonged loading distal to deviation
27
List the methods of treatment for ALD
Stall rest Controlled exercise Splints and casts Hoof manipulation Radial pressure wave therapy HCPTE Transphyseal staple Transphyseal bridge (screws and wire) Transphyseal screw
28
At what age does the rapid growth stage end for: MCIII/MTIII and proximal phalanx; tibia and radius
MCIII/MTIII proximal phalanx: 2 months Tibia: 4 months Radius: 6 months
29
What are the landmarks for PE at the distal radial physis
3cm vertical incision between CDE and LDE tendons, starting from point 4-5cm proximal to distal physis of radius and continuing proximally
30
Which ALD, when it is mild, is protective against carpal fracture and effusion
Carpal valgus
31
List the causes of congenital flexural limb deformity
Intrauterine malpositioning: Rare If large foal Diseases acquired by mare during pregnancy Agents ingested during pregnancy: Locoweed Hybrid Sudan grass Dominant gene mutation in sire Equine gioter Influenza Neuromusclar disorders Lathyrism: Defects in cross-linking of elastin and collagen Glycogen branching enzyme deficiency: QH (transient flexural deformity)
32
What are the treatment options for digital hypertension deformities
Swimming Farriery: Shorten toe Rasp palmar half of foot Heel extensions Bandaging : Phalangeal region Tenoplasty: Mini foals - NOT recommended
33
How does oxytetracycline work
3g in 250-500mL physiologic saline administered slowly IV. Administer 2-3 times in first week. Induces dose-dependent inhibition of collagen gel contraction by equine myofibroblasts and indices a dose-depended decrease in MMP-1 mRNA expression by myofibroblasts. Basically oxytetracycline inhibits tractional structuring of collagen fibrils by equine myofibroblasts through an MMP-1-mediated mechanism.
34
What are the treatment options for treating acquired flexural limb deformity of the DIP jt
Nutrition: Early weaning Decrease mare ration Decrease foal concentrate ration Evaluate soil and water for trace mineral composition Physiotherapy and exercise: Controlled exercise Analgesia: Farriery: Protect toe Toe extension if small deformity Rasp heels if in contact with ground Cast: 10-14 days maximum Surgery: Desmotomy of ALDDFT DDFT tenotomy
35
Which vessel can be damaged and is usually ligated in a medial approach to performing desmotomy of the ALSDFT
Cephalic
36
List the type of sesamoid fracture
Apical Midbody]Basal Abaxial Sagittal Comminuted
37
Regarding all types of sesamoid fractures, what percentage returned to racing after surgical and conservative management
Surgery: 64% Conservative: 37%
38
What are the 4 types of P2 fracture
Dorsal or palmar/plantar intra-articular osteochondral chip fractures Palmar/plantar eminence fractures Axial fractures Comminuted fractures
39
What are the treatment options for lunation/subluxation of the PIP jt
Arthrodesis But some cases are due to excessive tension on DDFT so transection of medial head of DDFT can help
40
What the tenoscopy landmarks for transection of the PAL
The arthroscope is inserted just distal to the PAL halfway between the digital neurovascular bundle and the ergot. The lateral or medial entrance portal is positioned lateral or medial to the respective edge of the SDFT. The instrument portal is made 5 to 10 mm proximal to the PAL in the DFTS out pouching almost lateral to the SDFT.
41
Where should the distal screw be placed in a lateral condylar fracture
Centrally in the lateral condylar fossa
42
What is the prognosis for return to racing for displaced lateral condylar fractures
50%
43
Overall, what percentage of condylar fractures return to racing
70-80%
44
Where should plates be positioned for diaphyseal fractures of MCIII
Dorsolaterally and dorsomedially
45
Define a saucer fracture
A dorsal cortical fracture that curves proximal and courses back to the dorsal cortex
46
47
List the ultrasonographic features that indicate tendon injury
Enlargement Hypoechogenicity Reduced striated pattern Changes in shape, margin, position Irregular striated pattern indicates fibrosis Heterogenous pattern indicates chronic tendinopathy
48
What intralesional medications can be used in tendon injury
PSGAGs: Inhibit collagenases and metalloproteinases Inhibit macrophage activation Intralesion or M 76% return to work vs 46% controls Improved echogenicity of U/S HA: Component of tendon matrix Contains: D-glucuronic acid N-acetyl-D-glucosamine Peritendinous, intralesional, intrathecal, systemically No difference in reinjury Less tendon enlargement cf controls Peritendinous injection may reduce lameness Decreases adhesions when administered intrathecally Decreases inflammation and hemorrhage Beta-aminopropionitrile fumarate Methylprednisolone: Dystrophic mineralization and tissue necrosis - avoid Ultrasonographic guidance standing or GA 2.5cm 22Ga needle for not treatments NOT for first 3 days after injury as can increase hemorrhage Large volumes can be damaging New advances: Tissue engineering approaches:IGF-1: Stimulates extracellular tendon matric synthesis Mitogen Decreases initial swelling Recombinant equine growth hormone: IM Decreased yield point and ultimate tensile strength TGF-B: Fewer reinjuries at site but more on contralateral limbs More tendon enlargement PRP: Plasma with at least twice the platelet concentration of normal plasma Contains: PDGF TGF-B VEGF Stimulates cell proliferation and matrix synthesis ACELL VET: Intralesional therapy using acelllular tissue from porcine urinary bladder submucosa Bone marrow: Intralesional MSCs: Differentiate into tenocytes to regenerate tendon matrix Functionally superior repear Reinjury rate 26% (in 3 years) - improved from conventional treatment
49
What is the purpose of tendon splitting
Decompresses core lesion by evacuating serum or hemorrhage and facilitate vascular ingrowth, may reduce propagation of lesion Faster resolution of lesion, quicker revascularization and increased collagen deposition cf controls
50
What is the prognosis for return to function following busoscopy for DDFT tears
28%
51
Describe the procedure for a neurectomy and fasciotomy for hindlimb proximal suspensory desmitis
GA, dorsal recumbency 4-6cm incision adjacent to lateral border of SDFT, originating proximally from level of chestnut Plantar metatarsal fascia incised and incision extended deep to SDFT by blunt dissection, facilitated by retraction of SDFT Deep branch of lateral plantar nerve located and transected using scalpel and 3cm section removed Fasciotomy performed adjacent to lateral splint bone
52
53
Describe the pathophysiology of P2 plantar eminence fractures
Uniaxial or biaxial Result of hyperextension of PIP jt, with tension on palmar/plantar attachments of SDFT, middle scutum and distal sesamoidean ligaments Occasionally, soft tissues can be disrupted without bone damage
54
List the treatment options for a subchondral cystic lesion of P2
IA HA - temporary pain relief Surgical curettage: Transosseous drilling Small drill bit under fluoroscopic control (inject saline into joint to confirm correct placement of drill) Enlarge to 5.5mm drill bit Allows access of curette to evacuate cyst Lavage joint Cyst and drill hole filled with tricalcium phosphate granules (or fibrous gel with PTH1-34) Arthrodesis (but multiple lesions have a poor response)
55
What is the ethology of proximodorsal osteochondral fractures of P1
Common in racehorses and non-racehorses Caused by hyperextension of MCP jt with impact of proximal and dorsal aspect of proximal phalanx onto dorsal region of MCIII Does not seem to be genuine OC
56
List the consequences of not removing proximodorsal osteochondral fractures of P1
Erosion of opposing metacarpal condyle (lameness) Synovitis Cartilage degeneration Villonodular synovitis
57
What are the two types of palmar/plantar osteochondral fractures of P1
Type I fractures: Avulsed from axial, proximal, plantar or palmar rim of proximal phalanx and are mostly articular Insertion of short sesamoidean ligament still attached to avulsed fragment Minimal lameness, usually at trot Type II fractures: Larger, abaxially located, partly articular osteochondral fragments Extend distad 2-3cm and contain minimal articular cartilage No persistent lameness May constitute delayed form of ossification
58
How should a closed fetlock lunation be treated?
Cast 6 weeks Apply under GA
59
Discuss the treatment of chronic proliferative (villonodular) synovitis of the fetlock and how size of the lesion influences treatment
If \<4mm: IA atropine and steroids If \>4mm:Surgery:Arthroscopy:Small masses: Synovectomy instruments, guarded scalpels, biopst suction punch rongeur, radiofrequency probe Large masses: Large biopsy punch rongeurs, CO2 or diode laser Athrotomy
60
Describe the treatment of sagittal fractures of the proximal sesamoid bone
3.5mm cortex screws in lag fashion in lateral-to-medial orientation MCP arthrodesis occasionally necessary: If injury to intereseamoidean ligaments or P1 fracture also Post-op: Cast for 2-3 weeks Then heavy bandage Retire from racing as usually concurrent condylar fracture
61
What is the prognosis for return to function for basilar sesamoid fractures?
Poor Inverse relationship between dorsopalmar fragment length and likelihood of return to racing Basal osteochondral fragments that do not extend to palmar surface: 59% return to racing 57% return to racing if fragment involves \<25% of base 40% return to racing if fragment involves \>25% of base
62
What is the aetiology of palmar osteochondral disease (POD) of the fetlock joint?
Trauma: Accumulated stress and sclerosis developing during racing, particularly hyperextension Degenerate metacarpal condyle has acellular and necrotic bone, with zone of new bone formation deep to this: remodelling and fracture changes Early lesions have little cartilage damage, however, eventual fracture and displacement of subchondral bone results in complete bone and cartilage loss

Equine Surgery: QOD (13 decks)

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